Proximal Left Anterior Descending Artery Acute Occlusion With an Unusual Electrocardiographic Pattern: Not Everything Is ST Elevation

Evolutionary de Winter pattern: from de Winter ECG to STEMI-A case report

Background

De Winter pattern is associated with acute occlusion in the left anterior descending coronary artery combined with upsloping ST-segment depression at the J point in leads V₁ through V₆ without ST-segment elevation. The ECG changes in this case were illustrated by an up-sloping ST-segment depression in the V₁ to V₆ leads, followed by tall and symmetrical T waves. Changes from de Winter to ST-segment elevation myocardial infarction (STEMI) are rare.

Case presentation

Our case illustrated an evolutionary de Winter sign that changed to STEMI; the patient underwent cardiac catheterization in time.

Conclusions

Patients who have an electrocardiogram showing de Winter changes may require primary percutaneous coronary intervention. Emergency physicians and cardiologists should not ignore these changes.

The de Winter ECG pattern: Distribution and morphology of ST depression

Background

The reported positive predictive value (PPV) for the “de Winter ECG pattern” to predict an acute left anterior descending artery (LAD) lesion is inconsistent. Besides, the morphology of upsloping or nonupsloping ST depression (STD) may have different significance of severity and prognostication.

Methods

We searched the MEDLINE database using “de Winter” or “junctional ST‐depression with tall symmetrical T‐waves” or “tall T wave” or “STEMI equivalent” as the item up to March 2020. We compared the ECG differences between the different culprit arteries and various morphological STD.

Results

A total of 70 patients with analyzable ECGs were included. In 60 patients (LAD group), the LAD was the culprit artery, while in 10 patients (non‐LAD group), there were other etiologies. Maximal STD in V2 or V3 had a PPV of 89% of all patients and 98% of patients without ST elevation in V2 to detect an acute LAD lesion. The presence of q/Q‐wave or poor R‐wave progression in the precordial leads was significantly more often found in patients with upsloping STD than in patients with nonupsloping STD in the LAD group (84% vs. 27%, p < .01). In 18 patients, the ECG showed a change from upsloping to nonupsloping STD from the leads with maximal STD to the surrounding leads with less STD.

Conclusions

The location of the maximal STD in the precordial leads differs between patients with LAD as the culprit artery and other etiologies of the de Winter ECG pattern. Upsloping STD signifies more severe signs of ischemia than nonupsloping STD.

A rare transitory change of the De Winter ST/T-wave complex in a patient with cardiac arrest: A case report

RATIONALE

The De Winter ST/T-wave complex is a rare and special electrocardiogram (ECG) manifestation in some patients with a total or subtotal occlusion in the proximal left anterior descending (LAD) coronary artery. It mainly appears as an ST-segment superior oblique depression instead of an ST elevation. However, a transitory change of the De Winter ST/T-wave complex has not been reported previously.

PATIENT CONCERNS

A 40-year-old man developed sudden precordial dull and unrelieved pain. One hour later, he suddenly lost consciousness when he arrived at the emergency department. After successful cardiopulmonary resuscitation (CPR), 2 ECGs were taken at 22-minute interval, which showed completely different manifestations. The first ECG showed acute inferior-wall ST elevation myocardial infarction (STEMI), while the second ECG showed a De Winter ST/T-wave complex, which indicated acute anterior-wall myocardial infarction.

DIAGNOSIS

The patient was diagnosed with acute myocardial infarction.

INTERVENTIONS

The patient responded to urgent treatment by percutaneous coronary intervention (PCI).

OUTCOMES

It was confirmed that the case was consistent with the main characteristics of a De Winter ST/T-wave complex after PCI. The first ECG was a rare transitory change of the De Winter ST/T-wave complex. The patient was well recovered and discharged.

LESSONS

The De Winter ST/T-wave complex is an extremely dangerous and rare ECG manifestation that is not widely recognized at present. Although the mechanism is not very clear, it should be considered as indicating an equivalent risk of STEMI because it may suggest total or subtotal occlusion in the proximal LAD coronary artery. It is believed that in the near future, the mechanism of ECG including its transitory changes, will be fully revealed.